神经内镜硬膜下岩前入路中2种Kawase三角相关骨性解剖标志定位方法的应用解剖学观察

Applied and anatomic observation of two methods for locating related bony anatomic landmarks associated with the Kawase triangle in the intradural anterior subtemporal transpetrosal approach

目的探讨神经内镜硬膜下岩前入路中2种Kawase三角相关骨性解剖标志的定位方法,为临床应用提供解剖学依据。方法(1)选取成人干性颅骨标本16具,在颅骨上标记弓状隆起最高点(A)、岩尖(P)、岩浅大神经沟最外侧缘点(B)、棘孔最外侧缘点(C)、卵圆孔最外侧缘点(D)、三叉神经压迹最外侧缘点(E)、破裂孔的最外侧缘点(F)及岩骨嵴外侧缘-横窦前缘交汇点(J)。硬膜下岩前入路定位方法a:以A点为参照点,P点、J点连线(PJ)为基线,过A点作PJ的平行线AP1,过B、C、D、E、F点做AP1的垂线,交点为B1、C1、D1、E1、F1。测量AB、AC、AD、AE、AF、BB1、CC1、DD1、EE1、FF1的长度,利用三角函数计算∠BAP1、∠CAP1、∠DAP1、∠EAP_(1)、∠FAP1的角度。定位方法b:以A点为参照点,AP为基线,测量AB、AC、AD、AE、AF、AP的长度,利用三角函数计算∠BAP、∠CAP、∠DAP、∠EAP、∠FAP的角度。(2)选取湿性尸头标本2具,女1具、男1具,年龄47岁、61岁。在2具湿性尸头标本分别模拟神经内镜硬膜下岩前入路手术,术中分别根据2种定位方法在干性颅骨标本上测量的相关角度、线段长度定位B、C、D、E、F点的位置。依据解剖标志点的定位,在Kawase三角安全范围内显露Kawase三角,磨出骨窗。观察从悬吊完硬膜至切开Kawase三角硬膜的操作时间,测量骨窗的大小。观察2种定位方法模拟手术操作中有无损伤或离断岩浅大神经、三叉神经下颌支、岩上窦,以评估2种定位方法的临床适用性。结果(1)定位方法a测量的AB、AC、AD、AE、AF、BB1、CC1、DD1、EE1、FF1的长度分别为(11.41±1.22)、(23.99±1.17)、(30.36±1.60)、(22.22±2.95)、(32.08±2.29)、(3.92±0.82)、(10.82±1.53)、(10.88±1.73)、(1.10±1.23)、(2.24±2.10)mm,∠BAP1、∠CAP1、∠DAP1、∠EAP_(1)、∠FAP1的角度分别为:20.1°±4.0°、26.8°±4.9°、21.0°±4.8°、2.8°±5.0°、4.0°±4.0°。定位方法b测量的AB、AC、AD、AE、AF、AP的长度分别为(11.03±2.36)、(22.11±2.92)、(24.66±3.00)、(19.10±2.94)、(29.46±2.57)、(29.83±3.37)mm,∠BAP、∠CAP、∠DAP、∠EAP、∠FAP的角度分别为51.0°±12.7°、47.0°±7.6°、40.1°±4.1°、23.9°±5.9°、16.6°±3.0°。(2)2具湿性尸头标本模拟神经内镜硬膜下岩前入路,均顺利完成解剖标志点的定位,充分显露Kawase三角安全范围,完成骨窗磨除。操作过程中无岩浅大神经、三叉神经下颌支、岩上窦及周围神经血管的离断或损伤。方法a,悬吊完硬膜至切开Kawase三角硬膜的操作时间分别为5 min 48 s、6 min 47 s,磨出骨窗的大小分别为27.90 mm×41.08 mm、34.24 mm×46.26 mm;方法b,悬吊完硬膜至切开Kawase三角硬膜的操作时间分别为4 min 7 s、4 min 57 s,磨出骨窗的大小分别为24.54 mm×33.72 mm、28.14 mm×41.4 mm。结论在神经内镜硬膜下颞下岩前入路手术中,以弓状隆起最高点为参照点,以弓状隆起最高点与岩尖连线为基线,能够精准定位术中Kawase三角的相关骨性结构,该定位方法更适用于临床手术操作。

Objective This study aimed to explore a suitable method for locating related bony structures in the intradural anterior subtemporal transpetrosal approach under endoscopy and to provide anatomical basis for clinical practice.Methods(1)The following were marked on 16 dry skulls:the highest point of arcuate eminence(A),petrous apex(P),most lateral point of groove for the greater petrosal nerve(B),foramen spinosum(C),foramen ovale(D),trigeminal impression(E),foramen lacerum(F)and intersective point of the lateral margin of the petrous ridge and the anterior edge of the transverse sinus(J).Method a used point A as the reference point,line PJ as the baseline,and line AP1 as the parallel line of baseline.Points B,C,D,E,and F were passed as the vertical line of AP1.The intersection points were B1,C1,D1,E1,and F1.The lengths of AB,AC,AD,AE,AF,BB1,CC1,DD1,EE1,and FF1 were measured,and the angles of∠BAP1,∠CAP1,∠DAP1,∠EAP_(1),and∠FAP1 were calculated using trigonometric functions.Method b used point A as reference point and line AP as the baseline.The length of AB,AC,AD,AE,AF,AP were measured,and the angle of∠BAP,∠CAP,∠DAP,∠EAP,and∠FAP were calculated using trigonometric functions.(2)Two wet head specimens were provided,and one female aged 47 years and one male aged 61 years were selected.The positions of points B,C,D,E,and F were located according to the relevant angle and line length measured on the skull specimen by using the two positioning methods.According to the positioning of anatomical landmarks,the Kawase triangle was exposed and the bone window was ground out.The operation time from suspending the dura to cutting the Kawase triangle dura and the size of the ground bone window were measured.We further determined whether the superficial greater petrosal nerve,the mandibular branch of trigeminal nerve,and the superior petrosal sinus were injured or disconnected during the simulated operation of the two localization methods to evaluate the clinical applicability of the two localization methods.Results(1)The lengths of AB,AC,AD,AE,AF,BB1,CC1,DD1,EE1,and FF1 measured by method a were(11.41±1.22),(23.99±1.17),(30.36±1.60),(22.22±2.95),(32.08±2.29),(3.92±0.82),(10.82±1.53),(10.88±1.73),(1.10±1.23),and(2.24±2.10)mm,respectively.The angles∠BAP1,∠CAP1,∠DAP1,∠EAP_(1),and∠FAP1 were 20.1°±4.0°,26.8°±4.9°,21.0°±4.8°,2.8°±5.0°,and 4.0°±4.0°,respectively.The lengths of AB,AC,AD,AE,AF,and AP measured by method b were(11.03±2.36),(22.11±2.92),(24.66±3.00),(19.10±2.94),(29.46±2.57),(29.83±3.37)mm,respectively.The angles∠BAP,∠CAP,∠DAP,∠EAP,and∠FAP were 51.0°±12.7°,47.0°±7.6°,40.1°±4.1°,23.9°±5.9°,and 16.6°±3.03°,respectively.(2)Using the anatomical data of methods a and b,the relevant bone structures in the subdural anterior petrosal approach were located,and no peripheral nerve and blood vessel injury were found.For method a,the operation time from suspending the dura to cutting the Kawase triangle dura was 5 min 48 s and 6 min 47 s,and the ground bone window was 27.90 mm×41.08 mm and 34.24 mm×46.26 mm.For method b,the operation time from suspending the dura to cutting the Kawase triangle dura was 4 min 7 s and 4 min 57 s,and the ground bone window was 24.54 mm×33.72 mm and 28.14 mm×41.4 mm.Conclusion In the neuroendoscopic intradural anterior subtemporal transpetrosal approach,the arcuate eminence is used as the reference point.The line between and the highest point of the arcuate eminence and the petrous apex are used as the baseline,which can accurately locate the relevant bone structures during operation.This positioning method is more suitable for clinical surgery.